Robert W. Tofte

Toxic shock syndrome: clinical and laboratory features in 15 patients.

Toxic shock syndrome is a recently recognized illness with serious morbidity and mortality that occurs primarily in healthy menstruating women who use tampons. Thirteen women and two men were evaluated; two of the women died in spite of seemingly appropriate therapy. All patients had a temperature of 38.9 degrees C or greater, hypotension of syncope, a skin rash with subsequent desquamation, mucous membrane inflammation, and laboratory evidence of multiple organ dysfunction. Staphylococcus aureus was isolated from the cervix or vagina in eight women and from soft-tissue infections in both men. Two patients were bacteremic. The significant heterogeneity in the clinical manifestations, laboratory abnormalities, and therapeutic requirements among patients may result in diagnostic confusion and inappropriate therapy. Although toxic shock syndrome appears to be associated with tampon usage and S. aureus, the pathogenesis remains unknown.

Toxic Shock Syndrome: Clinical, Laboratory, and Pathologic Findings in Nine Fatal Cases

Clinical, laboratory, and pathologic findings in nine of the 12 patients who died from toxic shock syndrome in Minnesota are reported. All patients met the toxic shock syndrome case definition except for desquamation, which occurred in only one patient. Eight were menstruating and at least four were wearing tampons at the time of the acute illness. One patient was using napkins only. Noncardiogenic pulmonary edema was the only clinical development that could be used to predict a fatal outcome. Specific pathologic findings included various degrees of fatty metamorphosis of the liver; pronounced hemophagocytosis by reticuloendothelial macrophages; and a characteristic vaginal lesion consisting of mucosal separation beneath the basal layer with ulceration, severe vasodilatation, inflammation and thrombosis, but with minimal bacterial invasion. This vaginal lesion was noted in two tampon users, but an identical lesion was found in a menstruating patient who used only napkins.

Toxic Shock Syndrome: Management and Long-Term Sequelae

Little information is available on the optimal management of toxic shock syndrome and on its sequelae. The most appropriate antibiotic treatment, the efficacy of colloid infusions, and the potential role of gamma globulin preparations have not yet been completely ascertained. Coagulase-positive staphylococci associated with toxic shock syndrome had minimal inhibitory concentrations of 0.06 microgram/mL or less to rifampin, 0.25 microgram/mL or less to gentamicin, and 0.50 microgram/mL or less to both nafcillin and clindamycin. In the 36 patients studied abnormal chest roentgenograms were commoner in those who had received albumin than in those who had not. Radioimmunoassay showed antibody titers to staphylococcal enterotoxin F, a marker protein in toxic shock syndrome, of 1:4000 or more for intravenous gamma globulin (12/15 lots) and 1:40 000 or more for intramuscular gamma globulin. Major sequelae of toxic shock syndrome include late-onset rash, compromised renal function, cyanotic extremities, and prolonged neuromuscular abnormalities.

Clinical and Laboratory Manifestations of Toxic Shock Syndrome

We studied 28 women and two men, with a median age of 20 years, who first had toxic shock syndrome between 1 February 1980 and 15 July 1981. Two of these patients died. All patients had intense myalgia, high fever (greater than or equal to 38.9 degrees C), hypotension or syncope, skin rash and desquamation, and abnormalities in at least three organ systems. Over half had sterile pyuria; immature granulocytic leukocytosis; coagulation abnormalities; hypocalcemia; low serum albumin and total protein concentrations; and elevations of blood urea nitrogen, alanine transaminase, bilirubin, and creatine kinase. Staphylococcus aureus was isolated from cultures from sites of soft-tissue infection in both male patients and from 13 of 19 vaginal and eight of 12 cervical cultures. All isolates produced both pyrogenic exotoxin C and enterotoxin F. All patients with a febrile, exanthematous, multisystem illness, particularly one associated with menstruation or a staphylococcal infection, should be promptly evaluated and empirically treated for toxic shock syndrome.

Toxic shock syndrome

Toxic shock syndrome (TSS) is an exotoxin-mediated illness that occurs primarily in young menstruating women who use tampons. The syndrome ranges from a potentially fatal disease characterized by hypotension and failure in multiple organ systems to a less severe condition commonly misdiagnosed as a nonspecific viral illness or gastroenteritis. Physicians should recognize that an exanthematous, febrile illness that recurs during menstruation or that occurs primarily in the postoperative or postpartum period and in association with staphylococcal infections may be TSS even in the absence of requisite diagnostic criteria. Unless TSS can be excluded with reasonable certainty, appropriate cultures should be obtained, with treatment initiated presumptively. In all menstrual cases, women should be advised to avoid tampon use indefinitely.